Implementing Dialectical Behavior Therapy With Adolescents and Their Families in a Community Outpatient Clinic☆

https://doi.org/10.1016/j.cbpra.2007.08.004Get rights and content

Abstract

Dialectical behavior therapy (DBT), an empirically supported treatment for adult women diagnosed with borderline personality disorder (BPD), has been increasingly adapted for use with adolescents across a variety of settings. This article describes a community-based application of DBT principles and strategies for adolescents and their families. It is the first study of DBT with suicidal and self-injuring adolescents to provide parent as well as adolescent reports of change. Uncontrolled pre- to posttreatment effects ranged from d = .62 to .94 for adolescent-reported depressive symptoms, anger, dissociative symptoms, overall symptoms and functional difficulties, and items on which adolescents reported wanting to hurt or kill themselves. Not only did parents report similar changes (d = .55 to .65) in adolescent internalizing, externalizing, and total problem behaviors, they reported a large change (d = .72) in their own depressive symptoms as well. The consistency of these effects with those of other preliminary studies of adolescent DBT suggests that this model is indeed feasible within a naturalistic community treatment setting and may have benefits for families as well as adolescents.

Section snippets

Participants

This adolescent DBT program was initiated for adolescents with behavioral patterns similar to those of adult BPD. Brochures encouraged referrals of adolescents with difficulty managing intense emotions without injuring themselves, entering into crisis, or seriously disrupting relationships. Referrals came from inpatient units, parents, therapists, therapeutic programs, schools, and adolescents themselves. All adolescents and parents or caregivers participating in the program between September

Adolescent Functioning by Adolescent Self-Report

The Reynolds' Adolescent Depression Scale (RADS; Reynolds, 1987) is a 30-item self-report measure designed to assess clinically relevant depressive symptoms in adolescents. Adolescents rate how often each item applies to them on a 4-point scale (from almost never to most of the time). Internal consistency reliability (Cronbach's alpha) has been consistently high (.90 to .96). Test-retest reliability has also been supported and there is extensive evidence of content, convergent, and discriminant

Suicidal Ideation

Reduction of suicidal and life-threatening behaviors is the highest-priority target in DBT. We found large and significant decreases in frequency of “wanting to hurt self” (n = 27, d = .62, p = .004) and “wanting to kill self” (n = 27, d = .73, p = .001). Of clinical significance, the percentage of those wanting to kill themselves dropped from 32% to 5% and the percentage of those never wanting to kill themselves increased from 32% to 63%. Similarly, while 50% endorsed wanting to hurt themselves “lots” or

Discussion

As one of the earliest adaptations of DBT for adolescents, this program helped establish the feasibility of conducting DBT with adolescents and collecting pre-post treatment data in a community outpatient treatment setting. Clinicians from a variety of backgrounds and with limited training in cognitive behavioral therapies committed time to learning the treatment model and participating in a weekly consultation team. In contrast to other programs (e.g., Rathus & Miller, 2002) in which a small,

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    ☆

    The authors would like to acknowledge the generous support and assistance from William Cook, Alec Miller, Matthew Nock, Ellen Zimmerman, and Douglas Robbins, and the great effort of the many clinicians and clients who made this study possible.

    1

    Kristen A. Woodberry is now a graduate student in the Clinical Psychology Program at Harvard University. Ellen J. Popenoe is now a neuropsychologist in the Developmental Behavioral Pediatrics Division of the Maine Pediatric Specialty Group in Falmouth, ME.

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